Do we really want to be customers?

20th May 2005 at 01:00
We all expect to be treated as customers when we visit the supermarket to buy groceries, and we all want to make choices about what we buy there. But is it really possible to transfer the retailer-customer relationship to health and education?

In recent years consumption - the selection and purchase of goods and services by individuals at their leisure - has been elevated to the summit of human achievement. This fetishisation serves a useful political end, as it switches the public's focus from work to leisure. If we live to consume rather than live to work, then finding fulfilment in our jobs becomes secondary to the issue of what we can buy with what we earn.

Michael Keaney of the department of postgraduate medical education at the University of Glasgow, questions the rise of the patient as consumer in the NHS. His arguments, outlined in a provocative paper for the International Journal of Social Economics, could equally be applied to the relationship between schools and students. Increasingly, teachers are seen as having "customers", rather than pupils.

The NHS has undergone an unprecedented series of upheavals over the past 25 years, the most recent and dramatic of which is the introduction of the concept of patient choice. But few understand the fundamental shift in thinking needed if patients are to be treated as "consumers". Michael Keaney argues that the idea of choice is seductive: it seemingly tips the balance of power away from the doctor "provider" towards the patient"consumer". Part of this new ethos of consumerism, which is viable only in a competitive environment, means that league tables of "performance" must be published, charting the relative success or failure of hospitals and clinicians. The same happens in schools.

But perhaps the analogy between patient and consumer has been driven too far, to the point at which it is no longer useful and could even be dangerous. Medicine, after all, is one of the most complex branches of knowledge, requiring more study at university level than almost any other discipline. And the knowledge base of some branches within medicine - such as biochemistry - is doubling every few years. Can the concept of an informed consumer making self-protective choices in this environment have any kind of meaning?

It is true that the NHS needed to pay more attention to patients'

requirements and wishes; there have been years of complacency, and management techniques adapted from commerce have helped to refocus organisational attitudes. But the nature of the relationship between doctor and patient and teacher and student is qualitatively very different from that between, for example, a bank manager and a customer.

Doctors and teachers establish relationships in which the asymmetrical distribution of power is sharply defined. Effective management of such relationships depends on trust; this could be damaged by the redefinition of patients as customers. It could also be argued that the imbalance of knowledge makes the term "customer" meaningless. The same could be said of the relationship between teachers and students. When it comes to my healthcare I do not want to be a customer, I would much prefer to stay a patient. But are patients being given that choice? No.

Dr Raj Persaud is Gresham professor for public understanding of psychiatry, and director of the Centre for Public Engagement, King's College London.

His latest book is The Motivated Mind (Bantam Press). Email:

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